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Bioterrorism briefing: Q&A with Arthur Reingold, public health expert

Reingold talks about what preparations we've made, quarantining and forced vaccination, and the long-term sickness of the public health system.
31 October 2002

By Bonnie Azab Powell and Jeffery Kahn, Public Affairs

BERKELEY - Most of us have stopped worrying about getting sick from opening our mail, but the threat and fear of bioterrorism has not abated. Evidence has mounted that the 2001 anthrax attacks were not the work of a rogue individual, but of a sophisticated foreign terrorist organization. Without question, Iraq has biological weapons. And in early October, the federal Centers for Disease Control and Prevention (CDC) recommended that more than 500,000 hospital workers around the country receive vaccinations in case of a smallpox attack.

    Art Reingold
'But even if we had the perfect piece of detection equipment, we have bigger issues: how much would they cost, how many trained people are needed to run them, where do you put them — in Las Vegas but not in Reno? in San Francisco and L.A. but not in Redding?'
—Professor Art Reingold, director of Berkeley's Center for Infectious Disease Preparedness

We decided to ask UC Berkeley public-health expert Arthur Reingold, M.D., about the nation's state of readiness for biological attacks. Head of the epidemiology division at the School of Public Health, Reingold recently received a $2.8 million grant to establish a new Center for Infectious Disease Preparedness, part of a national network of academic centers that will train emergency personnel. Before joining UC Berkeley's faculty, he was assistant chief of the Special Pathogens Branch of the CDC's Bacterial Diseases Division.

In October of last year you said that the U.S. was far less prepared than it could be for a bioterrorism attack. Do you think that's still true? What progress have we made?

Basically, it's still true. There are two aspects of this preparation: general public health preparedness and things that are specific to bioterrorism, like smallpox vaccinations. We're much better prepared for the latter. As a nation we've commissioned large quantities of a modern smallpox vaccine and have large stores of the old vaccine, which we've learned can be diluted and still give protection. And we're at least talking about getting plans in place for how you use the vaccine and how you vaccinate people. There are moneys going to medical facilities to try and improve their level of readiness, funds are being spent to develop central repositories of drugs and various kinds of medical equipment that could be flown somewhere within hours. Those kinds of quick-response things are certainly in the works; some existed before 9/11 and some have been expanded greatly since then.

So if you're talking about specifics for things like smallpox, those are happening at a speed that's maddeningly slow, incredibly fast, or just about right, depending on your point of view.

What about developing systems that can detect an attack before people get sick?

Technology that can detect organisms in the environment using an air or a soil sample has been advancing over the last several years; the military has had such technology as far back as the Gulf War. Obviously those efforts have been given added impetus from the Department of Defense. Such devices still have some marked limitations, some of which may be amenable to engineering and some that won't. They're still not 100 percent specific — there are organisms that look like anthrax that some of the machines cannot tell apart — so we're likely to have false positives. But even if we had the perfect piece of detection equipment, we have bigger issues: how much would they cost, how many trained people are needed to run them, where do you put them — in Las Vegas but not in Reno? in San Francisco and L.A. but not in Redding? Where in San Francisco?

So we'll probably have to rely on the traditional public health means of detection, where the doctor is first to identify an outbreak.

Most likely. In a battlefield situation, with a finite area, monitoring the environment makes sense, but when you're talking about trying to protect the entire U.S., clearly there a lot of decisions still to be made. But what people like about that idea is that we may be able to detect the problem before people get sick: using people as the sentinel canaries obviously lacks appeal.

For people in public health who do the kind of work I do, the much more central issue is about monitoring of illness in the population, for example if someone does something terrible like sprinkle salmonella in a salad bar or spray smallpox virus in JFK airport. If you accept the notion that some people — at least one — have to get sick before we can detect the problem, then the question is how good is the existing system for detecting that, what are the communications that are available, what's being done to improve those factors. It's not just whether we're prepared for bioterrorism, but whether the basic public health infrastructure in general is ready to detect and respond quickly to problems.

And is it?

The infrastructure is still woefully inadequate in some ways, and that's a problem. It's better than it is in most countries. It's been good enough to serve the country and society reasonably well, but it's certainly not nearly as good as it could or should be, and the reason for that is a fundamental lack of interest in paying for public health at the local and state level.

Public health has been under-funded for decades. Health departments have fewer people than they should, and those they do have are not as well trained as they should be. The salaries are low, the infrastructure is bad, the staff support is poor, and the opportunities for continuing education are almost nonexistent. While there are some wonderfully talented people working in public health, they're not there because of all the great things public health has to offer them.

After 9/11, we learned that many public health departments don't have email or fax machines. Have we at least improved the communications system?

There's been a longstanding effort to improve the electronic communication of data for reporting of diseases, so that if a doctor sees a case of tularemia or plague, say, he or she transmits that information electronically via the Internet in a secure manner. That information would then be rapidly shared from the county to the state to the CDC (national level). For several years now, the CDC has been working on moving from a very archaic 19th-century approach in which doctors fax or mail in these cards. But connecting all these doctors and counties and states is not a trivial challenge: there are enormous issues around hardware, software, security, privacy, and training individuals to use it. We're a while away from adopting electronic reporting nationally.

Art Reingold    
'We have never forcibly vaccinated someone against their will in this country. We have in other countries, in the smallpox eradication program in South Asia in the 1970s. I am pretty sure we would not permit that here.'
—Professor Art Reingold

In the meantime, what we have in place is a system where doctors and labs and nurses and other health professionals have requirements to report things to the county health department, which reports to the state. But all the laws about reporting diseases are state laws, not federal. So if the CDC wants to make a particular disease reportable, it has to coordinate with 50 different states.

The system does a reasonable job of detecting and responding to problems. Some small outbreaks might get missed. But when you start talking about bioterrorism, would the system detect an anthrax or a smallpox attack? Absolutely.

Would the system detect an attack rapidly enough to contain it?

That's the 64-dollar question, and it depends on a lot of imponderables. If somebody were to spray anthrax over New York City, how "rapid" is rapid enough? And what is "contain"? Some people will die. The only question is, what proportion of those deaths would be preventable by earlier detection and a certain series of actions unfolding.

State legislatures are debating whether to adopt what's called the Model State Emergency Health Powers Act, which would give them the legal power to test people against their will, vaccinate them, quarantine an area, and seize property to be used as treatment facilities. Are those kind of actions necessary? Aren't they already legally available to health officials?

You have to be careful in lumping all these measures together. In terms of quarantine, my guess is that the laws exist that would allow the health department to close bridges, limit movement, and have forcible quarantine. As a public health person, I guess I think if we truly had something like a smallpox outbreak in California, such measures would be reasonable. Historically, we’ve been willing to limit the movement of people to prevent the spread of infection. So if somebody refuses to take their tuberculosis medication, there's a legal basis for restraining them in their home, jail, or the hospital until they complete their treatment — we can't otherwise protect the public from someone walking around coughing out multi-drug-resistant TB.

Forced vaccination is not in the same league, however. We have never forcibly vaccinated someone against their will in this country. We have in other countries, in the smallpox eradication program in South Asia in the 1970s. I am pretty sure we would not permit that here.

With the caveat that I'm not a lawyer, my understanding is that virtually every state has laws that give the health commissioner of department powers like those to protect the public's health. Now, many of those laws are 100 years old or more and have never been tested in court. But I think that in an emergency if somebody were to say, "I don't care what you say about the smallpox, I'm still getting on that airplane," we'll need some public health authority to prevent that. Maybe certain civil libertarian groups would not agree, but I think most of the public would.

But under what circumstances do you quarantine people and limit movement? Who has the authority to do what? Right now such emergency actions still need public discussion, with politicians and community leaders and all types of people involved.

Does the idea of bioterrorism keep you awake at night?

Well, I've always had a certain skepticism about this topic. However, the anthrax attacks of last fall if nothing else say that perhaps one can be too sanguine. Maybe the people who say it's not "if" but "when" have the better sense. But since it's absolutely impossible to me to predict whether there will be other bioterrorism attacks or what agent will be used where, I can't assess the risks or therefore calculate the benefits of spending billions of dollars to be better prepared for this, say, to vaccinate people for smallpox.

I do know that we have lots of other health problems needing attention, and so there are trade-offs. State budgets are in the tank. California and other states have had to freeze hiring, freeze travel, and cut costs wherever they can. So at the same time that parts of the health department are getting better, others are being slashed. What you have now is more people doing smallpox surveillance and fewer people working on tuberculosis or sexually transmitted diseases, because those areas are frozen or being cut.

With all the other cuts going on, are things better than they would have been in the absence of those federal dollars? Sure. There are improvements in some ways that are directly related to public health, but I can't say there's a net improvement.

But I sleep soundly every night, and I get up each morning assuming there will not be a smallpox outbreak in Berkeley. I hope that I am right. This is a pretty crazy world these days.